Declaration For Default Or Uncontested Dissolution / Legal Separation Page 2
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3FL-170
CASE NUMBER:
PETITIONER:
RESPONDENT:
6.
Child custody and visitation (parenting time) should be ordered as set forth in the proposed Judgment (form FL-180).
a.
The information in Declaration Under Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) (form FL-105)
has not
changed since it was last filed with the court. (If changed, attach updated form.)
has
b.
There is an existing court order for custody/parenting time in another case in (county):
The case number is (specify):
c.
The current custody and visitation (parenting time) previously ordered in this case, or current schedule is (specify):
Contained on Attachment 6c.
d.
Facts in support of requested judgment (In a default case, state your reasons below):
Contained on Attachment 6d.
7.
Child support should be ordered as set forth in the proposed Judgment (form FL-180).
a.
If there are minor children, check and complete item (1) if applicable and item (2) or (3):
(1)
Child support is being enforced in another case in (county):
The case number is (specify):
(2)
The information in the child support calculation attached to the proposed judgment is correct based on my
personal knowledge.
I request that this order be based on the
petitioner’s
respondent’s earning ability. The facts in support
(3)
of my estimate of earning ability are (specify):
Continued on Attachment 7a(3).
b.
Complete items (1) and (2) regarding public assistance.
(1)
am receiving
am not receiving
intend to apply for
public assistance for the child or children
I
listed in the proposed order.
(2)
To the best of my knowledge, the other party
is
is not
receiving public assistance.
c.
The petitioner
respondent
is presently receiving public assistance, and all support should be made
payable to the local child support agency at the address set forth in the proposed judgment. A representative of the local
child support agency has signed the proposed judgment.
8.
Spousal, Partner, and Family Support (If a support order or attomey fees are requested, submit a completed Income and
Expense Declaration (form FL-150) unless a current form is on file. Include your best estimate of the other party’s income.
Check at least one of the following.)
a.
I knowingly give up forever any right to receive spousal or partner support.
b.
I ask the court to reserve jurisdiction to award spousal or partner support in the future to (name):
c.
I ask the court to terminate forever spousal or partner support for:
petitioner
respondent.
d.
Spousal support or domestic partner support should be ordered as set forth in the proposed Judgment (form FL-180)
based on the factors described in:
Spousal or Partner Support Declaration Attachment (form FL-157)
written agreement
attached declaration (Attachment 8d.)
e.
Family support should be ordered as set forth in the proposed Judgment (form FL-180).
f.
Other (specify):
Page 2 of 3
FL-170 [Rev. July 1, 2012]
DECLARATION FOR DEFAULT OR UNCONTESTED
DISSOLUTION OR LEGAL SEPARATION
(Family Law)
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